Annual Statement of Changes in Beneficial Ownership (5)
21 February 2014 - 10:07AM
Edgar (US Regulatory)
FORM 5
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Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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Form 3 Holdings Reported
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X
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Form 4 Transactions Reported
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0362
Estimated average burden
hours per response...
1.0
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
Tsumpes William
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2. Issuer Name
and
Ticker or Trading Symbol
T3 Motion, Inc. [TTTM]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
__
X
__ 10% Owner
__
X
__ Officer (give title below)
_____ Other (specify below)
CEO, Interim CFO
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(Last)
(First)
(Middle)
2990 AIRWAY AVENUE, BLDG. A
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3. Statement for Issuer's Fiscal Year Ended
(MM/DD/YYYY)
12/31/2013
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(Street)
COSTA MESA, CA 92626
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form Filed by One Reporting Person
___ Form Filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I)
(Instr. 4)
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7. Nature of Indirect Beneficial Ownership
(Instr. 4)
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Amount
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(A) or (D)
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Price
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Common Stock
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11/8/2013
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P4
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19960
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A
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$0.08
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399117
(1)
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D
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Common Stock
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12/20/2013
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G4
(2)
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12500
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D
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$0
(2)
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399117
(1)
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D
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Common Stock
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12/25/2013
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G4
(2)
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7460
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D
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$0
(2)
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2634065
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I
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T Energy, Inc.
(3)
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
(MM/DD/YYYY)
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of Derivative Securities Beneficially Owned at End of Issuer's Fiscal Year
(Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I)
(Instr. 4)
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11. Nature of Indirect Beneficial Ownership
(Instr. 4)
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Convertible Debentures
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$.1
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11/26/2012
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P
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1000000
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11/26/2012
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11/26/2014
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Common Stock
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1000000
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$1
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1000000
(4)
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I
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T Energy Inc.
(3)
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Warrants
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$.1
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11/26/2012
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P
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1000000
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11/26/2012
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11/26/2014
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Common Stock
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1000000
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$1
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1000000
(5)
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I
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T Energy Inc.
(3)
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Explanation of Responses:
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(
1)
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On November 8, 2013, 19,960 shares of the shares of common stock of T3 Motion, Inc. (the "Company") were purchased by the Reporting Person, all of which were subsequently gifted on December 20, 2013 and December 25, 2013, leaving the Reporting Person's direct ownership amount unchanged as of the fiscal year end.
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(
2)
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The shares of Common Stock purchased by the Reporting Person were gifted to employees of the Company on December 20, 2013 and to family members on December 25, 2013.
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(
3)
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These shares are held by T Energy, Inc. The Reporting Person is a controlling person of T Energy, Inc. as he is the sole officer, director and shareholder of that company. The Reporting Person has sole voting and sole dispositive control over the shares and derivative securities held by T Energy, Inc.
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(
4)
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These debentures were received as a component of debenture units purchased by the Reporting Person at a price of $1.00 per unit, each such unit consisting of (i) one share of common stock, (ii) ten five year warrants with an exercise price of $0.10 per warrant and (iii) $1.00 of non-interest bearing senior secured convertible debentures convertible at the holder's option into shares of the Company's common stock at a conversion price of $0.10 per share.
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(
5)
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These warrants were received as a component of debenture units purchased by the Reporting Person at a price of $1.00 per unit, each such unit consisting of (i) one share of common stock, (ii) ten five year warrants with an exercise price of $0.10 per warrant and (iii) $1.00 of non-interest bearing senior secured convertible debentures convertible at the holder's option into shares of the Company's common stock at a conversion price of $0.10 per share.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Tsumpes William
2990 AIRWAY AVENUE, BLDG. A
COSTA MESA, CA 92626
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X
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X
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CEO, Interim CFO
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Signatures
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/s/ William Tsumpes
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2/14/2014
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number.
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